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GYNAECOLOGY

Stephen Kruger is a generalist gynaecologist and deals with all aspects of gynaecology. If for any reason the problem is one that he does not feel absolutely confident in treating he will readily refer to an appropriate colleague who is an expert in that particular field, the same way as colleagues refer to him for his expertise.

COLPOSCOPY

Stephen is particularly interested in HPV Virus and abnormal smears. He can perform colposcopies and endeavours to see women quickly and if treatment is required then it will be done and completed within a month.

A colposcopy is a detailed examination of the cervix (entrance to the uterus) with a specially lit microscope (colposcope). As with a Pap smear, an instrument called a speculum is inserted into the vagina, and then the colposcope is used with its light directed on the cervix.

A colposcopy is performed if your Pap smear has shown abnormal or cancerous cells on the cervix. During the colposcopy, further samples of tissue (biopsies) are usually removed and examined in the laboratory so the doctor can get a clearer idea of the extent of the abnormal cells.They should not be painful but if they are it’s like a pinprick.

FIBROIDS

Fibroids are noncancerous growths or tumors on the muscular part of the uterus (womb); sometimes they are also called myomas. Fibroids may be very small (about 5mm) or can grow to be quite large (about 100mm).

Many women with fibroids do not notice any symptoms and will not need treatment, whereas others may experience problems such as painful and heavy periods. Treatment includes medication to shrink the fibroids, embolization and, in some women, surgical removal of the fibroids (myomectomy ) or a hysterectomy.

HEAVY PERIODS

An area of special interest to Stephen is that of heavy menstrual bleeding, especially fibroids. He will explore all aspects of management including medical and surgical options.

HORMONE REPLACEMENT THERAPY – HRT

Hormone replacement therapy (HRT) is when female hormones (oestrogen by itself or with progesterone) are given to a woman during or after menopause when the production of oestrogen by the ovaries declines. The hormones can be taken as tablets, implants or skin patches.

HRT has become less popular in recent years because a large study in the USA found that long-term use of HRT can increase the risk of some serious diseases, such as breast cancer and blood clots. Many subsequent studies have found the original study to be flawed. For some women, short-term use of HRT (no more than 3–4 years) can provide relief from symptoms caused by having less oestrogen in their bodies, such as hot flushes and loss of bone density and sexual issues,

The risks and benefits of HRT should be thoroughly discussed with a doctor before treatment begins.

HYSTEROSCOPY – Dilatation & Curettage

Dilatation and Curettage (D&C) is an operation where the cervix (entrance to the uterus) is dilated and a hysteroscope (small lighted mini telescope) is inserted into the uterus through the vagina and cervix so the specialist can see the inside of the uterus. A small spoon-like instrument with a long handle, called a curette, is inserted and the lining of the uterus is scraped off and sent to the laboratory for examination.

This procedure can be done under a general (you are asleep) or local (you are awake and the area being investigated is numb) anesthetic.

CERVICAL DYSPLASIA

Cervical dysplasia is the growth of abnormal cells around the cervix (entrance to the uterus). Although this condition is not cancer there is a small risk that these cells could become cancerous.

Sometimes no treatment is needed as the condition may improve by itself. For more severe dysplasia, treatment involves removing the abnormal cells by freezing, laser therapy (a tiny beam of light) or electrical burning (Lletz). Whether you have treatment or not, you should have more frequent Pap smears in the future.

EARLY PREGNANCY COUNSELLING

Stephen does early pregnancy counselling and care from conception to 15 weeks. Together with you, he will develop a plan to monitor early pregnancy progress that reassures couples that all is going well. After 15 weeks, he will arrange for you to be transferred to the LMC of choice.

Stephen has a special interest in miscarriages and recurrent miscarriages. He has developed an easy monitoring system that will alert us early if things are not going well.

INFERTILITY

Stephen will investigate and counsel couples who are struggling to fall pregnant. He will use clomiphene or letrozole,  cycle tracking with ultrasound, and timed intercourse. Stephen has developed a plan which is simple, inexpensive and has a good success rate

MENOPAUSE

Menopause is also called the “change of life” and is the time when your periods will become irregular and stop. This is a natural process in all women and for most, it will occur between the ages of 45 and 55 years.

Menopause is brought on by decreasing levels of the hormone oestrogen and this can cause a variety of symptoms, including hot flushes, night sweats, mood swings, sleeping problems, memory problems, depression and vaginal dryness. Some women do not notice any symptoms or they are very mild, whereas others experience more severe problems and should go to their doctor for advice.

There are many treatments available to reduce the symptoms associated with menopause and, in some cases, lifestyle changes can also help.

MIRENA INSERTION & REMOVAL

The Mirena IUCD is a useful non-surgical method of controlling heavy menstrual bleeding. It works extremely well and in many instances. With its use, a hysterectomy can be avoided.I also inset the Jaydess intrauterine device and Multiloads.If the insertion is complex and difficult I offer to insert it under anesthetic where indicated.

PAP SMEAR

A Pap smear is a test to check for signs of cancer on the cervix (entrance to the uterus). A doctor will put an instrument called a speculum into the vagina to open it, and then gently wipe or brush a few cells from the cervix to send to the laboratory for testing. A Pap smear can show if cervical cells are going through any changes that happen before cancer grows. It will also show if cancer cells are present.

Regular Pap smears make it possible to prevent cancer before it grows, or to pick up cancer early so that it is more easily cured. A National Cervical Screening Programme aims to provide all New Zealand women with regular smears and recommends that a Pap smear be done every three years between the ages of 20 and 70 years.

Stephen is often asked to perform difficult or extremely uncomfortable smear test and has a number of little tricks, developed over the years, to make it easier and less painful including the use of local anesthetic.

POLYCYSTIC OVARIAN SYNDROME

Polycystic ovarian syndrome (PCOS) is a hormonal disorder that can cause you to have a variety of symptoms, including no periods or irregular periods, increased hair growth on the face and body, acne (pimples) and increased body weight. PCOS is also one of the main causes of infertility in women. The ovaries of women with PCOS often contain many small cysts (fluid-filled sacs), but this does not seem to be the cause of the condition.

For women who have not reached menopause, the most common treatment is the birth control pill, which will regulate your periods. There are also other medicines that can help control the symptoms.

PROLAPSE & PELVIC FLOOR WEEKNESS

Stephen’S wife is a PHD scientist researching the pelvic floor and he shares her interest in it and offers a number of options for care.

VAGINAL INFECTIONS

The most common vaginal infections are yeast infections (also called candidiasis or thrush), trichomoniasis, or bacterial infections (also called bacterial vaginosis). Symptoms of an infection may include irritation, itching, discharge, and odor.

To make a diagnosis a doctor will usually do a vaginal swab, which involves wiping a type of cotton bud gently across the infected area. The swab is then sent to the laboratory for analysis. There are many medicines that can successfully treat these infections.

VULVAL CONDITIONS

In early November 2012, Stephen was privileged to attend a fantastic and informative conference in Auckland run by the AUSTRALIA AND NEW ZEALAND VULVOVAGINAL SOCIETY, he would to share some of what was discussed.

First, let’s explain the anatomy. The vulva is the collective term applied to the female external genitalia, comprising the outer parts of the female genital tract. It is the parts that are visible to the naked eye. The vulva extends from the mons pubis at the top to the anus at the bottom and the groin on both sides.

Starting at the top and working downwards.

  1. Mons Pubis this is the fatty part that covers the pubic bone. It is where pubic hair grows.
  2. Labia are what are termed the lips. The outer lips are called the labia majora and the inner lips the labia minora.The labia majora are covered with hair and the labia minora are not. The labia minora size does vary from individual to individual.
  3. This is found where the two labia minora unite at their upper end. The clitoris is made out of erectile tissue. It is similar in design to the male penis with a glans, prepuce and spongy tissue.
  4. Urethral orifice. This is where the urine comes out. It is a short tubular structure and is found between the vaginal opening and the clitoris.
  5. As with the clitoris being at the top of the labia minor the fourchette is at the bottom.
  6. This is the opening of the vagina.

That very briefly is the anatomy. He has developed over the years an interest in this part of gynaecology. The conditions that affect the vulva and vagina are very debilitating, embarrassing and unpleasant. They are however mostly very treatable or at the very least manageable. Below is a brief discussion of the more common conditions. As with any medical condition, it is always best to consult your usual health professional for a diagnosis and treatment.

The itchy sensitive vulva

The vulval skin is a very specialized skin and therefore extremely sensitive to a number of irritants. Irritation can cause stinging, burning and itching.

The commonest cause is not thrush but a local chemical that causes irritation. The most common ones are soaps, scented and dyed toilet paper, perfumes, deodorants, sanitary towels, waxing, flavoured lubrication products, shaving, and condoms.

Itching due to thrush is less common but obviously must be excluded as a cause.

The treatment is to try and identify the causative agent, remove it and treat the symptoms. A topical steroid cream will alleviate the itch and burn.

If thrush is documented then anti-fungal medication will cure it.

Lichen Sclerosis

Lichen Sclerosis is an inflammatory skin condition. It can affect people of all ages and both sexes. On the genital area, it is more common in women and more common in older women with the peak age being peri and post-menopausal.

The symptoms are an itch, soreness, and painful intercourse (dyspareunia) bleeding and white areas on the skin. About one-quarter of patients are asymptomatic.

The best way of making an accurate diagnosis is to take a biopsy which is to take a small skin sample or a few under local anesthetic.

The long-term consequences of Lichen Sclerosis are the loss of tissue of the labia minora, narrowing of the vaginal entrance and adhesions (scarring) across the clitoris with resultant loss of clitoral exposure and loss of clitoral tissue.

There is also a small malignant potential. The treatment of choice is long-term high doses steroid cream or ointment. Although there is no cure this form of treatment alleviates symptoms and retards tissue loss.

Very important. Because of the malignant potential regular check-up are essential.

Lichen Planus

This is an autoimmune skin condition less common than Lichen Sclerosis. The symptoms are pain, dyspareunia, discharge, loss of anatomy and ulceration

It also has a malignant potential. The diagnosis is again made with a biopsy. The treatment is also steroid cream and long-term follow up.

Lichen Simplex Chronicus

This condition is a chronic dermatitis (inflammation of the skin). It is often caused by chronic itching and scratching. The labia majora is often involved.

The treatment is to try and identify the causative agents that are causing the irritation and avoid those. Topical steroid cream is used and night sedation as the itching is worse at night.

Atrophic Vaginitis

This is a condition of oestrogen deficiency. It is usually seen in post-menopausal women. Symptoms are vaginal dryness, itching, painful intercourse, recurrent thrush infections, and an urgency feeling in the bladder.

The treatment is local topical oestrogen creams or pessaries.

Stephen has also written an article for my website on the practical approach to vulval itching that would be worth a read.

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